REPUBLIC OF THE PHILIPPINES)

PROVINCE OF NUEVA VIZCAYA) S.S.

MUNICIPALITY OF BAYOMBONG)

AFFIDAVIT OF LOSS

I, LUDIVINA NAVARRO MANGABAT, of legal age, married, Filipino

citizen, and a resident of Brgy. San Nicolas, Bayombong, Nueva Vizcaya, after
having been duly sworn to in accordance with law, hereby depose and state:

1. That I am a bonafide holder of Pawn Ticket with No. PTA 5470 that represent
the earings I pledged to Tambunting Pawnshop located at Bayombong,
Nueva Vizcaya, on February 15, 2017;
2. That I pawned one (1) pair of earrings to the above-mentioned pawnshop;
3. That lately, I discovered that said Pawn Ticket was misplaced and/or
intermixed with my personal belongings and that diligent efforts have been
exerted to locate the same but it was nowhere to be found, hence I now
consider it lost beyond recovery;
4. That I am executing this affidavit to attest to the truth of the foregoing.

IN WITNESS WHEREOF, I have hereunto set my hand this 3rd day of April
2017 at Bayombong, Nueva Vizcaya.

LUDIVINA NAVARRO MANGABAT

Affiant
PRC ID No. 001916727

SUBSCRIBED AND SWORN TO before me this 3rd day of April 2017 at

Bayombong, Nueva Vizcaya. Affiant having exhibited to me her competent
identification card, indicated below her name and signature.